The Clinical Documentation Specialist is responsible for ensuring the accuracy and completeness of clinical documentation in patient medical records. This role involves reviewing medical records, identifying documentation gaps, and collaborating with healthcare providers to improve documentation practices.
Key Responsibilities:
* Review patient medical records for accuracy and completeness.
* Identify documentation gaps and inconsistencies.
* Collaborate with healthcare providers to improve documentation practices.
* Provide education and training to healthcare providers on documentation requirements.
* Ensure compliance with regulatory and coding guidelines.
Required Skills:
* Clinical background (RN, LPN, or related field)
* Medical coding knowledge
* Strong analytical skills
* Excellent communication skills
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